By David P. Steensma, MD
2009-12-07
Initiatives to improve health in the developing world have
traditionally focused on reducing the terrible burden that infectious diseases
place upon poor people. Although preventable and treatable infections still
needlessly claim millions of lives each year, innovative governmental programs
coupled with the work of philanthropic groups have resulted in real progress
against endemic infections. As populations in many nations are aging and infant
mortality trends downward, efforts to reduce the worldwide toll exacted by
cancer are attracting more attention from public health organizations.
Globally, hematologic malignancies such as acute
promyelocytic leukemia (APL) are much less common than neoplasms related to
tobacco use or viral infections. However, hematologic cancers are potentially
more treatable, and therein lie opportunities.
In conjunction with the 2004 ASH Annual Meeting, several
experts in APL met with hematologists from developing countries to form the
International Consortium on Acute Promyelocytic Leukemia (IC-APL). The IC-APL’s
long-term goals include improving clinical care for patients with APL in the
developing world and creating infrastructure for clinical trials and
translational research. The IC-APL continues to be an active international
collaborative effort, with plans to expand the number of countries
involved.
APL is an excellent disease choice for a demonstration
project of this kind, in part because the cure rate is high in countries with
excellent medical resources and well-developed health-care infrastructure — and
also because APL is more common in Latin American populations, so that many of
the most motivated APL investigators are from South and Central America.
The early results of the IC-APL initiative are
promising. In yesterday’s Plenary Session, Dr. Eduardo Rego from the University of São Paulo
in Brazil presented data
from 102 patients enrolled in the IC-APL by researchers in the first three
participating countries: Brazil,
Mexico, and Uruguay
(abstract #6). The investigators used a modified version of the PETHEMA-LPA
2005 regimen developed in Spain,
which includes all-trans-retinoic acid (ATRA) plus idarubicin and mitoxantrone
in induction or consolidation, with cytarabine added
for high-risk patients. The consortium used daunorubicin as the anthracycline
of choice, which is considerably less costly than the idarubicin used in the PETHEMA-LPA
2005 study.
The two-year survival
achieved using the IC-APL regimen was 77 percent — comparable to survival
obtainable with ATRA and anthracycline-based therapy of APL in parts of the
developed world, but better than the 52 percent survival reported in a
Brazilian study that predated the IC-APL. The first few weeks after diagnosis
are a particularly dangerous time for patients with APL due to coagulopathy, and the IC-APL dropped
the 30-day mortality rate from 42 percent before the consortium’s formation to
just 16 percent with better early diagnosis and supportive care, approaching
outcomes in places with far greater medical resources.
Although the success of this cooperative effort is cause
for celebration, there is so much work yet to do. According to the 2007 United
Nations Human Development Index, Uruguay
ranked 50th, Mexico 53rd,
and Brazil
75th out of 182 surveyed states — all within the “wealthier” tiers of the
developing world. The poorest corners of the globe have almost no access to
high-quality cancer care of the type fostered by the IC-APL and, across large
parts of the world, lack of clean drinking water, chronic hunger, and the
effects of regional conflicts are still problems much greater than cancer.
Those of us who live in rich countries might take a moment to think how we can
lend a hand to our needier brothers and sisters, whether by developing
specialty-specific initiatives such as the IC-APL or through supporting
philanthropic groups and other non-governmental organizations.
Dr. Steensma indicated no relevant conflicts of
interest.
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